HospitalInspections.org

A. Based on document review and interview, it was determined that for 1 of 1 (Pt #1) sentinel event reviewed, the Hospital failed to ensure that the registration process for an unresponsive patient in the ED was followed, as required.

Findings include:

1. The Hospital's policy titled, "Patient Identification" (origination date 9/2015) was reviewed on 7/31/19 at approximately 9:50 AM, and included, " ...II. POLICY: Patients will be accurately identified at the time of intake ...and prior to the delivery of care, treatment or services by using at a minimum two patient identifiers (name and date of birth). III. SCOPE: This policy/procedure applies to all patients ...and emergency department ...IV. PROCEDURE: A. Confirm the patient's identity prior to all care, treatment or services by using the following two unique patient identifiers ...1. Acceptable two-identifiers include: Name (first and last) Date of Birth ..."

2. The Hospital's policy titled, "Emergency Department Registration" (revised 7/2019) was reviewed on 7/31/19 at approximately 10:00 AM, and included, " ...III. This policy applies to Emergency Department registrars who are responsible for collecting patient demographics and financial information ...IV. Quick Registration (QER) is a short registration created to collect minimal patient information ...contains the patient's name, date of birth, gender and chief complaint. Full Registration (ERM) is the process of obtaining the vital patients demographics ...is completed after a patient has been assessed by a physician ...B. Patients presenting via ambulance: ( ...are quick registered and an armband secured in the Main Emergency Department area)."

3. The Hospital's process titled, "Cardiac Arrest/Unresponsive Processing" (origination date 6/2016) was reviewed on 8/1/19 at approximately 9:30 AM, and included, "When a patient arrives in cardiac arrest, unresponsive or unable to provide his/her unique identifiers (name, date of birth and/or social security number), the patient will be entered in STAR (computer registration program) with the name Doe, John or Doe, Jane and the default dob (1/1/1920) ..."

4. On 7/31/19 at approximately 10:30 AM the clinical record for Pt. #1 was reviewed. Pt. #1 was an unresponsive male patient brought in to the Hospital's ED by the Chicago Fire Department (CFD). The CFD ambulance run sheet dated, 4/29/19 at 7:12 AM only included Pt. #1's name and no other identifying information was available to confirm Pt. #1's identity. The Hospital's ED Registration sheet dated for the 4/29/19 admission did not indicate that Pt. #1 was registered as John Doe.

5. On 8/1/19 at approximately 9:59 AM, an interview was conducted with an ED Registrar (E #8). E #8 stated, "When we are registering a patient that comes into the ED...If the patient is brought in via ambulance and is unable to speak ...and if there is no information on the patient we register the patient as a John or Jane Doe ...If a patient comes in via ambulance and with a name that I cannot verify, and there is no date of birth we use a default DOB 1/1/1920 and list as John/Jane Doe. For this patient (Pt #1) I do not recall why I did not enter this patient as a John Doe. I can tell you that if I had this scenario today, I would register this patient as John Doe."

B. Based on document review and interview, it was determined that for 1 of 1 patient's (Pt. #1) root cause analysis (RCA) revieved, the Hospital failed to thoroughly conduct and complete the RCA, as required.

Findings include:

1. The Hospital's policy titled, "Patient Safety Event Management" (revised 12/17) was reviewed on 7/31/19 at approximately 10:20 AM, and included, "Patient Safety Event: An event, or condition that could have resulted or did result in harm to a patient ...5. A Root Cause Analysis (RCA) is performed ...concluded within 45 days ...8. Causal Factors and root causes identified as a contributing factor to the adverse event are identified and addressed with corrective actions."

2. On 7/31/19 the Hospital provided a Patient Safety Event Details/Root Cause Analysis (RCA) for Pt. #1. The RCA included, "Date of Event 4/29/19; Date Discovered 5/25/19; Date reported: 5/25/19; Date RCA Begun: 5/27/19...Casual Statement: The Hospital does not have a written policy in place to follow for identification of John Doe. Following standard of care/protocol. - Action Plan: Create a policy/process to address identification of John Doe, will include it in the Patient ID policy. Work with CPD on their standard protocol for identification of John Doe and make sure we align with their protocol. - Strength - Intermediate - Responsible Person - Social Work Manager - Due Date 6/30/19 - Status - In progress..." The RCA did not idicate that a gap in the ED resgistration process was followed. Further, the RCA was started on 5/27/19, and as of survey date 8/2/19, the RCA has not been completed (more than 2 months).

3. On 8/1/19 at approximately 2:20 PM, an interview was conducted with the Director of Case Management and Patient Safety (E #9). E #9 stated, "When I became aware of this event my investigation included reviewing the medical record of the patient involved...As of now staff in registration will register a patient as John Doe if they are unable to obtain two identifiers and they (registration staff) will let the social worker know of the John Doe case to assist with the identification process. We felt that staff followed our protocol/policy during the registration process. This patient (Pt #1) came in by ambulance with a name, no other form of identification. The registrar took the name and gave a default DOB and did not list as a John Doe. However the process ended up being the same whether he was identified as a John Doe or with the name that was registered. The same process would have been followed for a John Doe that we followed for Pt #1. In Quality meeting we stated that we were in process of doing an RCA (Root Cause Analysis) but due to confidentially we are not able to discuss details ...I will be honest with you, the RCA is not concluded, there are so many components to address and we were not able to complete in 45 days."